Insulin therapy continuous subcutaneous infusion

This medical device is a small, programmable pump that administers insulin via the infusion set, consisting of a cannula and a needle. It is designed to be used for insulin pump therapy (continuous subcutaneous insulin infusion, CSll). The patch pump is a variant that combines the infusion set with the pump in a common housing (usually referred to as the pod). This unit is applied to the skin as an adhesive patch and replaced after two or three days. It is controlled by a separate unit (the personal diabetes manager, PDM) with a wireless link to the pod. Patch pumps were introduced in the USA around 2007 and have been available in Europe since mid-2010. The MID is the electrical chassis for the single-use insulin management system (Fig. 9.7). 

Currently, the most advanced form of insulin therapy is the insulin pump, also referred to as continuous subcutaneous insulin infusion (CSII). Using the short- or rapid-acting insulins only, these pumps are programmed to provide a slow release of small amounts of insulin as the basal portion of therapy, and then larger bolus doses are injected by the patient to account for the consumption of food. 

The standard mode of insulin therapy has traditionally been by subcutaneous injection using disposable needles/syringes. However, other routes of administration, including continuous subcutaneous insulin infusion pumps and inhalation of finely powdered aerosolized insulin, are currently being explored. 

Insulin delivery by a pump may be superior to glargine insulin. Continuous subcutaneous insulin infusion was compared with intensive therapy with insulin glargine plus insulin lispro in 19 patients (224). The patients who received insulin glargine were exposed to glucose concentrations under 3.9 mmol/1 overnight for three times as long as those who used continuous subcutaneous insulin infusion. 

Catheter malfunction was the most frequent event (obstruction, total occlusion, and peritoneal adhesions 13,10, and 3.1 events per 100 patient-years respectively). Flushing sometimes prevented occlusion. Better tip design had a big effect. Adhesion formation decreased with daily injections of heparin. The frequency of ketoacidosis was comparable to that reported with continuous subcutaneous insulin infusion and was usually related to catheter obstruction. It diminished during the review period. Episodes of severe hypoglycemia were fewer than during intensive subcutaneous therapy. 

Raskin P, Bode BW, Marks JB, Hirsch IB, Weinstein RL, McGill JB, Peterson GE, Mudaliar SR, Reinhardt RR. Continuous subcutaneous insulin infusion treatment and multiple daily injection therapy are equally effective in type 2 diabetes. Diabetes Care 2003 26 2598-603. 

Pickup J, Keen H. Continuous subcutaneous insulin infusion at 25 years evidence base for the expanding use of insulin pump therapy in type 1 diabetes. Diabetes Care 2002 25(3) 593-8. 

Linkeschova R, Raoul M, Bott U, Berger M, Spraul M. Less severe hypoglycaemia, better metabolic control, and improved quality of life in type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy an observational study of 100 consecutive patients followed for a mean of 2 years. Diabet Med 2002 19(9) 746-51. 

DeVries JH, Snoek FJ, Kostense PJ, Masurel N, Heine RJDutch Insulin Pump Study Group. A randomized trial of continuous subcutaneous insulin infusion and intensive injection therapy in type 1 diabetes for patients with long-standing poor glycemic control. Diabetes Care 2002 25(11) 2074-80. 

Bode BW, Strange P. Efficacy, safety, and pump compatibility of insulin aspart used in continuous subcutaneous insulin infusion therapy in patients with type 1 diabetes. Diabetes Care 2001 24(l) 69-72. 

Hanaire-Broutin H, Melki V, Bessieres-Lacombe S, Tauber JP. Comparison of continuous subcutaneous insulin infusion and multiple daily injection regimens using insulin lispro in type 1 diabetic patients on intensified treatment a randomized study. The Study Group for the Development of Pump Therapy in Diabetes. Diabetes Care 2000 23(9) 1232-5. 

Maniatis AK, Klingensmith GJ, Slover RH, Mowry CJ, Chase HP. Continuous subcutaneous insulin infusion therapy for children and adolescents an option for routine diabetes care. Pediatrics 2001 107(2) 351-6. 

Lenhard MJ, Reeves GD. Continuous subcutaneous insulin infusion A comprehensive review of insulin pump therapy. Arch Intern Med 2001 161 2293-2300. 

CONTINUOUS SUBCUTANEOUS INSULIN INFUSION A number of pumps are available for continuous subcutaneous insulin infusion (CSII) therapy. CSII, or pump, therapy is not suitable for all patients because it demands considerable attention, especially during the initial phases of treatment. For patients interested in intensive insulin therapy, a pump may be an attractive alternative to several daily injections. Most pumps provide a constant basal infusion of insulin and have the option of different infusion rates during the day and night to help avoid the dawn phenomenon and bolus injections that are programmed according to the size and nature of a meal. 

Siebenhofer A, Plank J, Berghold A, Horvath K, Sawicki PT, Beck P, Pieber TR. Meta-analysis of short-acting insulin analogues in adult patients with type 1 diabetes continuous subcutaneous insulin infusion versus injection therapy. Diabetologia 2004 47(11) 1895-1905. 

Marshall, S. M., Home, P. D., Taylor, R., and Alberti, K. G. M. M., 1987, Continuous subcutaneous insulin infusion versus injection therapy A randomised cross-over trial under usual diabetic clinic conditions. Diabetic Med. 4 521-525. 

Reeves, M. L., Seigler, D. E., Ryan, E. A., and Skyler, J. S., 1982, Glycemic control in insulin-dependent diabetes meUitus Comparison of outpatient intensified conventional therapy with continuous subcutaneous insulin infusion. Am. J. Med. 72 637-680. 

Immunologic Insulin allergy is rare but as insulin is often an essential therapy it can cause major clinical problems. Sometimes a change to a less immunogenic insuhn is helpful, and if not continuous subcutaneous insulin infusion has been tried [11 ]. In one case desensitization was successful [12 ]. 

Bruttomesso D, Costa S, Bariussio A. Continuous subcutaneous insulin infusion (CSII) 30 years later still the best option for insulin therapy. Diabetes Metab Res Rev 2009 25 99-111. 

Fatourechi MM, Kudva YC, Murad H, Elamin MB, Tabini CC, Montori VM. Hypoglycemia with intensive insulin therapy a systematic review and metaanalyses of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. J Clin Endocrinol Metab 2009 94 729. ... 

For persons with type 1 diabetes, insulin replacement therapy is necessary to sustain life. Pharmacologic insulin is administered by injection into the subcutaneous tissue using a manual injection device or an insulin pump that continuously infuses insulin under the skin. Interruption of the insulin replacement therapy can be life-threatening and can result in diabetic ketoacidosis or death. Diabetic ketoacidosis is caused by insufficient or absent insulin and results from excess release of fatty acids and subsequent formation of toxic levels of ketoacids. 

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